• What is the optimal method of fetal surveillance in a SGA infant ?

• What is the frequency of fetal surveillance in a SGA infant ?

• What is/are the optimal test/s to time delivery ?

• Biophysical tests, including amniotic fluid volume, cardiotocography (CTG) and biophysical scoring are poor at diagnosing a small or growth restricted fetus.

• A systematic review of the accuracy of umbilical artery Doppler in a high–risk population to diagnose a SGA neonate has shown moderate.

• Umbilical artery Doppler• Cardiotocography (CTG)• Amniotic fluid volume • Biophysical profile • Middle cerebral artery • Ductus venusus (DV) & Umbilical vein Doppler

Umbilical artery Doppler

• In high-risk population , the use of umbilical artery Doppler has been shown to reduce prenatal morbidity & mortality

Umbilical artery Doppler • Umbilical artery Doppler should be performed

in all fetuses with an estimated fetal weight or an abdominal circumference < 10th percentile (I- A)

Umbilical artery Doppler • Umbilical artery Doppler should be the

primary surveillance tool in the SGA fetus.

Frequency of Normal Umbilical artery Doppler flow indices in SGA fetus:

• Defined by customized fetal weight standards 81 % of SGA fetuses have a normal umbilical artery Doppler

Management of Normal Umbilical artery Doppler flow indices in SGA fetus:

• Outpatient management is safe in this group

• When umbilical artery Doppler flow indices are normal it is reasonable to repeat surveillance every 14 days.

• More frequent Doppler surveillance may be appropriate in a severely SGA infant.

• However Compare to AGA, SGA fetuses with a normal umbilical artery Doppler are still at increased risk of neonatal morbidity & adverse neurodevelopmental outcome

Which Umbilical artery Doppler waveform index ?

• The large systematic review of test accuracy couldn't comment on which waveform index to use.

• Although PI has been widely adopted in the UK , an analysis using receiver operator curves found that IR had the best discriminatory ability to predict a range of adverse perinatal out come

Routine umbilical artery Doppler

• In a low risk or unselected population, systematic review found no conclusive evidence that routine umbilical artery Doppler benefits mother or baby.

• As , such, umbilical artery Doppler is not

recommended for screening an unselected population .

Cardiotocography (CTG)

• CTG should not be used as the only form of surveillance in SGA fetuses.

• Interpretation of the CTG should be based on short term fetal heart rate variation from computerized analysis (A)

The most useful CTG predictor:

• FHR variation is the most useful predictor of fetal wellbeing in SGA fetuses .

• A short term variation 3 ms (within 24 h of

delivery ) has been associated with a higher rate of metabolic acidemia & early neonatal death

• Comparison of cCTG with traditional CTG showed a reduction in perinatal mortality with cCTG but no significant difference in perinatal mortality excluding congenital anomalies

نوار ضربان قلب جنین1رده

: عبارتند از 1خصوصیات رده • 160 تا 110تعداد ضربان قلب پایه در محدوده طبیعی )از •

ضربان در دقیقه( ضربان در دقیقه (25 تا 6تغییر پذیری پایه متوسط )از•فقدان افت متغیر و دیر رس•وجود یا عدم وجود تسریع ضربان قلب •احتمال وجود افت زودرس ضربان قلب•

این گروه به عنوان "طبیعی" تلقی شده و نشان •دهنده این است که جنین در لحظه ثبت نوار ، از نظر

وضعیت اسید – باز در وضعیت طبیعی بسر می برد

CTG نوار 3 ردهخصوصیات این رده عبارتند از •فقدان تغییر پذیری پایه ضربان قلب جنین به همراه هر کدام از موارد ذیل:• - افت دیررس مکرر ضربان قلب •

- افت متغیر مکرر ضربان قلب - کندی ضربان قلب جنین )برادیکاردی(

الگوی سینوزوئیدال •این رده با رنگ قرمز )خطر( نشان داده شده و به عنوان "غیر طبیعی" •

تلقی گردیده و نشان دهنده وضعیت غیر طبیعی اسید- باز جنین در موقع ثبت نوار است.

در موارد مواجهه با این گروه الزم است که اقدامات فوری و •مناسب در جهت بهبودی وضعیت جنین صورت گیرد و در

دقیقه مشکل برطرف نشد ، 30صورتی که حداکثر در عرض زایمان مد نظر قرار گیرد .

: نوار ضربان قلب جنین2رده

زیرا این دسته از نوار به عنوان "حد واسط" تلقی می شود• یعنی رده "طبیعی " و 1که شامل تمامی الگوهایی است که جز رده

یعنی "غیر طبیعی" قرار نمی گیرند.2رده انجمن زنان و مامایی کانادا این رده را بعنوان "غیر معمول" نام •

گذاری گرده است.روش استانداردی برای بررسی وضعیت این جنین ها بیان •

نشده است. بطور کلی وجود تغییر پذیری پایه متوسط ضربان در دقیقه ( و تسریع ضربان 25 تا 6)دامنه معادل

قلب نشانگر وضعیت طبیعی تعادل اسید- باز جنین بوده و نیازی به زایمان فوری نیست

3 یا 1این بیماران باید مرتبا تا زمانی که تبدیل به رده •شوند، تحت نظر بوده و مکررا بررسی شوند.

Amniotic fluid volume

• Ultrasound assessment of amniotic fluid volume should not to be used as the only form of surveillance in SGA fetus

• Amniotic fluid volume is usually estimated by the single deepest vertical pocket (SDVP) or amniotic fluid index(AFI), although both correlate poorly with actual amniotic fluid volume

• Interpretation of amniotic fluid volume should be based on single deepest vertical pocket (SDVP).

• The incidence of an AFI ≤ 5 cm in a low risk population is 1.5%.

• Compared to cases with a normal AFI, the risk of perinatal mortality and morbidity was not increased in cases with isolated oligohydramnios (RR 0.7, 95% CI 0.2–2.7) nor in those with associated conditions, including SGA fetuses (RR 1.6, 95% CI 0.9–2.6).

Oligohydramnios is associated with labour outcome:

• a systematic review of 18 studies involving 10551 women, found an AFI ≤ 5 cm was associated with an increased risk of caesarean section for fetal distress (RR 2.2, 95% CI 1.5–3.4) and an Apgar score < 7 at 5 minutes (RR 5.2, 95% CI 2.4–11.3) but not acidaemia.

• limited information is available about the accuracy of oligohydramnios to independently predict perinatal mortality and substantive perinatal morbidity in non–anomalous SGA fetuses monitored with umbilical artery Doppler

Biophysical profile

• Consist of a NST + 4 ultrasound component : fetal movement, fetal muscle tone , amniotic fluid volume, fetal breathing movement .

• A BPP is an appropriate second line (back-up) testing strategy when the NST component is non-reactive or none – interpretable

Biophysical profile (BPP)

• Biophysical profile should not be used for fetal surveillance in preterm SGA fetuses.

• What is the optimal method of fetal surveillance in a SGA infant ?

• What is the frequency of fetal surveillance in a SGA infant ?

• What is/are the optimal test/s to time delivery ?